Informed Patient Consent and Authorization form for sharing of deidentified case report
I give my consent and authorization for this information about MY SELF/MY WARD/MY RELATIVE (indicate correct description) relating to my/his/her health to appear in an online E-log case record (case report) that will exist in social media such as whatsapp and facebook. I understanding the following:
1) Health professionals need to communicate about my problem with each other and share my detailed history as well as images of my body in clinical photographs, images of Radiology and other test reports. In the past this was routinely done using paper based files and in the electronic age as it is faster to communicate using electronic devices connected online, this is how my history and images will be shared, as an E log case report (other than the paper based file system that may still continue).
2) My information will be published online by my health-professionals without revealing my identity or any personal information such as identifiable names and numbers like phone numbers, PAN number, UID numbers etc., and Email addresses or house addresses and the professionals in the online forums will make every attempt to ensure my anonymity addressing me solely by my anonymized user-name.
3) I understand, however, that complete anonymity cannot be guaranteed. It is possible that after reading the E log case report, somebody somewhere- perhaps, for example, somebody who looked after me if I was in hospital or a relative-may identify me. The information that will be visible online will be the existing information that I provide in the form of patient input and new information will be added by many professionals processing my patient inputs in the online forum
4) The information may be published in online forums such as in whatsapp and facebook as well as in associated journals on paper as well as a blog in the internet as an E log case report and will be distributed worldwide
5)Information displayed in the E-log forum is not supposed to replace advice from the primary physician of the patient and my primary physician in charge will continue to look after me and make his own responsible decisions about my treatment.
6) The above information was explained to me in the language I understand.
Name & Signature of Consent Giver
Signature of Guardian/ Relative,
Name & Designation of Consent Taker
(Anonymized Identifier)
Address :
Mobile No:
*సమాచార సమ్మతి మరియు అధికార పత్రం*
విస్తరించిన విషయములు నాకు అర్ధమినివి:
నేను నా గురించి/ నా వార్డ్/ నా బంధువు యొక్క ఆరోగ్య పరిస్థితుల గురించి ఆన్లైన్ ఈ లాగ్ కేస్ రిపోర్ట్ తయారు చేసి సోషల్ మీడియా లో అనగా (in social media platforms such as) ఫేస్బుక్(Facebook), వాట్సఅప్(whatsapp) లో పోస్ట్ చేయుటకు అనుమతి ఇస్తున్నాను. ఈ క్రింది విస్తరించిన విషయములు నాకు అర్ధమినివి:
1. 1. నా ఆరోగ్య పరిస్థితులను, నా వ్యాధులకు సంబంధించిన టెస్ట్ రిపోర్ట్స్, రేడియాలజీ రిపోర్ట్స్ ఈతర డాక్టర్స్ తో చర్చించుటకొరకు ఆన్లైన్ ఈ లాగ్ కేస్ రిపోర్ట్ తయారు చేయపడుతున్నది. ఇంతకు ముందు ఈ విధమైన సమాచారాము కాగితపు రూపంలో జరుగుతుండేది. ఈ ఆన్లైన్ ఈ లాగ్ కేస్ రిపోర్ట్ ఎలెక్ట్రానిక్ పరికరాలతో సునాయాసంగా సులభంగా త్వరగా పంపవచ్చు.
2. నా పేరు, ఫోన్ నంబర్, పాన్, ఉఇడ్ నంబర్స్, ఈమేల్ అడ్రెస్ లను వెలువరించకుండా, నేను సమాచారం డాక్టర్స్ ఈ లాగ్ కేస్ రిపోర్ట్ లో ప్రచురిస్తారు. ఈ ప్రచురించిన ఈ లాగ్ కేస్ రిపోర్ట్కు తెలియని పెరు పెడతారు.
3. నా పూర్తి వివరాలు ఎవరు చూడకుండా, చదవకుండా దాచటం సాధ్యం కాకపోవచు. ఉదాహరణకు, నాకు సంబంధించిన విషయాలను నేను ఆసుపత్రి లో ఉన్నపుడు నా స్నేహితులు కానీ , బంధుమిత్రులు కానీ చూసి చదివే అవకాశం ఉంది. ఈ లాగ్ కేస్ రిపోర్ట్ లో ఉండే సమాచారం ద్వారా ఈతర డాక్టర్లు నా ఆరోగ్యముకు సంబంధించి ఆన్లైన్ లో చర్చించవచ్చు.
4. ఈ లాగ్ కేస్ రిపోర్ట్ ద్వారా సేకరించిన సమాచారం ఆన్లైన్ ఫోరమ్ లో, జర్నల్ క్లబ్ లో, జర్నల్స, సోషల్ మీడియా లో అనగా (in social media platforms such as) ఫేస్బుక్(Facebook), వాట్సఅప్(whatsapp) లో నా పేరు, వివరములు వెలువరించకుండా ప్రచురించవచ్చు.
5. ఈ లాగ్ ఫోరమ్ లోని ఎటువంటి సలహా సమాచారము వచ్చిన, నా ప్రస్తుత ప్రాథమిక వైధ్యుడు యొక్క సలహాలతో మాత్రమే మార్చబడును.నా చికిస్తకు సమబంధించిన పూర్తి బాద్యత నా ప్రాథమిక వైధ్యుడిది.
6. ఈ పయ ప్రక్రియ అంతయు నాకు అర్ధం ఇయే భాషలోనూ వివరించబడినది.
సమ్మతి యొక్క పేరు మరియు సంతకం:
సంరక్షకుడు/ బంధువుల సంతకం:
దాత పేరు మరియు హోదా:
సమ్మతించు వాడి పేరు మరియు హోదా:
సమ్మతి ఐడి:
అడ్రెస్ :
సెల్ నంబర్ :
*রোগীর সম্মতি পত্র*
আমি সম্পূর্ণ খোলা মনে এই মর্মে সম্মতি জ্ঞাপন করছি যে আমি নিজে/আমার পরিচিত/আমার আত্মীয় (সঠিক যায়গায় টিক চিহ্ন দিন) রোগ সংক্রান্ত তথ্য একটি অনলাইন ই-লগ কেস রেকর্ডে (কেস রিপোর্ট) প্রদর্শিত হবে যেটা হোয়াটসঅ্যাপ (whatsapp) এবং ফেইসবুক (facebook)- এই ধরনের সোশ্যাল মিডিয়াতেও অবস্থিত থাকতে পারে এবং এতে আমার কোন আপত্তি নেই। আমি নিম্নবর্ণিত তথ্যগুলি বুঝেছি যেগুলি হলঃ
১) আমার স্বাস্থ্য সমস্যা সম্পর্কিত রোগের ইতিহাস, আমার শরীরের ক্লিনিক্যাল ও রেডিওলজিক্যাল ছবি (যেমন- এক্সরে, সিটি স্ক্যান, এম আর আই) সহ অন্যান্য পরীক্ষার রিপোর্টগুলো স্বাস্থ্যসেবা প্রদানকারীগন নিজেদের মাঝে শেয়ার করতে পারেন। পূর্বে এটি নিয়মিতভাবে কাগজে-কলমে করা হতো এবং এটি ছাড়াও, প্রযুক্তির উৎকর্ষ সাধনের সাথে সাথে, এই যোগাযোগ কে আরও দ্রুত করতে বিভিন্ন ইলেকট্রনিক ডিভাইস বা প্ল্যাটফর্ম ব্যবহার করে রোগের তথ্য শেয়ার করা হবে, যেমনঃ অনলাইন ই-লগ কেস রেকর্ডের মাধ্যমে।
২) আমার স্বাস্থ্যসেবা প্রদানকারিগন আমার রোগের তথ্য কোন রকম ব্যাক্তিগত তথ্য (যেমনঃ নাম, নম্বর, ফোন নম্বর, প্যান নম্বর, UID নম্বর, ইমেইল এড্রেস, বাড়ির ঠিকানা ইত্যাদি) ছাড়াই অনলাইনে প্রকাশ করবেন।
৩) আমার ব্যাক্তিগত তথ্য কখনই অনলাইনে প্রকাশ করা হবে না কেবল আমার সাংকেতিক নামই সকলে জানবে আমার প্রতিটি পত্রের জন্য।
৪) আমাদের প্রাথমিক উদ্দেশ্য হল কোন ব্যাক্তির ব্যক্তিগত রোগ সম্পর্কে বিভিন্ন তথ্য, বিভিন্ন পারদর্শিগনের সঙ্গে মতবিনিময় করে এক তথ্য ভান্ডার তোলা যাতে সেই ব্যক্তি তার রোগ সম্পর্কে সঠিক ধারনা পায়।
৩) আমি বুঝি যে, সবসময় আমার এই শারীরিক গোপনীয়তা নিশ্চিত করা সম্পূর্নরুপে সম্ভব নয়, কারন উদাহরন স্বরূপ যিনি আমার দেখভাল করছেন বা আমার পরিচিতেরা আমাকে চিনে ফেলতে পারেন।
৫) আমার রোগের তথ্য কখনই বিকৃত করা হবে না, কিন্তু প্রয়োজনে তার বাক্যের গঠন, ব্যাকরণ ইত্যাদিতে প্রয়োজনীয় পরিবর্তন আনা হতে পারে।
৬) আমার রোগ সম্বন্ধীয় তথ্যগুলি সারা পৃথিবীব্যাপি একটি অনলাইন ই-লগ কেস রেকর্ডের মাধ্যমে প্রচার করে ছড়িয়ে দেয়া হবে এবং সেটি বিভিন্ন স্বাস্থ্য সংক্রান্ত পত্রিকাগুলিতে প্রকাশ হতে পারে।
৭) এই অনলাইন ই-লগ কেস রেকর্ডে প্রদর্শিত চিকিৎসা সংক্রান্ত তথ্যগুলি কখনই আমার প্রাথমিক চিকিৎসকের উপদেশের বিকল্প হতে পারে না এবং আমার প্রাথমিক চিকিৎসকই আমার চিকিৎসার জন্য চূড়ান্ত সিদ্ধান্ত নিবেন।
8) উপরে উল্লিখিত তথ্য আমাকে আমার ভাষাতে পরিষ্কার করে বুঝানো হয়েছে। এতে আমার সম্মতি আছে।
সম্মতি প্রদানকারীর নাম ও সাক্ষর
সাক্ষ্যপ্রদানকারীর (অভিভাবক/আত্মীয়) সাক্ষর
সম্মতি/সাক্ষ্য প্রদানকারীর ঠিকানা ও মোবাইল নং
সম্মতি গ্রহণকারীর নাম ও সাক্ষর
Previous version of the forms including Hindi and Bengali
Hindi
http://bmjcaselogvivek.blogspot.com/2017/09/consent-forms.html?m=1
Bengali
https://drive.google.com/file/d/0B9Hr8RrSXSgYbHUtRW14NzZsRDg/Vite
I give my consent and authorization for this information about MY SELF/MY WARD/MY RELATIVE (indicate correct description) relating to my/his/her health to appear in an online E-log case record (case report) that will exist in social media such as whatsapp and facebook. I understanding the following:
1) Health professionals need to communicate about my problem with each other and share my detailed history as well as images of my body in clinical photographs, images of Radiology and other test reports. In the past this was routinely done using paper based files and in the electronic age as it is faster to communicate using electronic devices connected online, this is how my history and images will be shared, as an E log case report (other than the paper based file system that may still continue).
2) My information will be published online by my health-professionals without revealing my identity or any personal information such as identifiable names and numbers like phone numbers, PAN number, UID numbers etc., and Email addresses or house addresses and the professionals in the online forums will make every attempt to ensure my anonymity addressing me solely by my anonymized user-name.
3) I understand, however, that complete anonymity cannot be guaranteed. It is possible that after reading the E log case report, somebody somewhere- perhaps, for example, somebody who looked after me if I was in hospital or a relative-may identify me. The information that will be visible online will be the existing information that I provide in the form of patient input and new information will be added by many professionals processing my patient inputs in the online forum
4) The information may be published in online forums such as in whatsapp and facebook as well as in associated journals on paper as well as a blog in the internet as an E log case report and will be distributed worldwide
5)Information displayed in the E-log forum is not supposed to replace advice from the primary physician of the patient and my primary physician in charge will continue to look after me and make his own responsible decisions about my treatment.
6) The above information was explained to me in the language I understand.
Name & Signature of Consent Giver
Signature of Guardian/ Relative,
Name & Designation of Consent Taker
(Anonymized Identifier)
Address :
Mobile No:
*సమాచార సమ్మతి మరియు అధికార పత్రం*
విస్తరించిన విషయములు నాకు అర్ధమినివి:
నేను నా గురించి/ నా వార్డ్/ నా బంధువు యొక్క ఆరోగ్య పరిస్థితుల గురించి ఆన్లైన్ ఈ లాగ్ కేస్ రిపోర్ట్ తయారు చేసి సోషల్ మీడియా లో అనగా (in social media platforms such as) ఫేస్బుక్(Facebook), వాట్సఅప్(whatsapp) లో పోస్ట్ చేయుటకు అనుమతి ఇస్తున్నాను. ఈ క్రింది విస్తరించిన విషయములు నాకు అర్ధమినివి:
1. 1. నా ఆరోగ్య పరిస్థితులను, నా వ్యాధులకు సంబంధించిన టెస్ట్ రిపోర్ట్స్, రేడియాలజీ రిపోర్ట్స్ ఈతర డాక్టర్స్ తో చర్చించుటకొరకు ఆన్లైన్ ఈ లాగ్ కేస్ రిపోర్ట్ తయారు చేయపడుతున్నది. ఇంతకు ముందు ఈ విధమైన సమాచారాము కాగితపు రూపంలో జరుగుతుండేది. ఈ ఆన్లైన్ ఈ లాగ్ కేస్ రిపోర్ట్ ఎలెక్ట్రానిక్ పరికరాలతో సునాయాసంగా సులభంగా త్వరగా పంపవచ్చు.
2. నా పేరు, ఫోన్ నంబర్, పాన్, ఉఇడ్ నంబర్స్, ఈమేల్ అడ్రెస్ లను వెలువరించకుండా, నేను సమాచారం డాక్టర్స్ ఈ లాగ్ కేస్ రిపోర్ట్ లో ప్రచురిస్తారు. ఈ ప్రచురించిన ఈ లాగ్ కేస్ రిపోర్ట్కు తెలియని పెరు పెడతారు.
3. నా పూర్తి వివరాలు ఎవరు చూడకుండా, చదవకుండా దాచటం సాధ్యం కాకపోవచు. ఉదాహరణకు, నాకు సంబంధించిన విషయాలను నేను ఆసుపత్రి లో ఉన్నపుడు నా స్నేహితులు కానీ , బంధుమిత్రులు కానీ చూసి చదివే అవకాశం ఉంది. ఈ లాగ్ కేస్ రిపోర్ట్ లో ఉండే సమాచారం ద్వారా ఈతర డాక్టర్లు నా ఆరోగ్యముకు సంబంధించి ఆన్లైన్ లో చర్చించవచ్చు.
4. ఈ లాగ్ కేస్ రిపోర్ట్ ద్వారా సేకరించిన సమాచారం ఆన్లైన్ ఫోరమ్ లో, జర్నల్ క్లబ్ లో, జర్నల్స, సోషల్ మీడియా లో అనగా (in social media platforms such as) ఫేస్బుక్(Facebook), వాట్సఅప్(whatsapp) లో నా పేరు, వివరములు వెలువరించకుండా ప్రచురించవచ్చు.
5. ఈ లాగ్ ఫోరమ్ లోని ఎటువంటి సలహా సమాచారము వచ్చిన, నా ప్రస్తుత ప్రాథమిక వైధ్యుడు యొక్క సలహాలతో మాత్రమే మార్చబడును.నా చికిస్తకు సమబంధించిన పూర్తి బాద్యత నా ప్రాథమిక వైధ్యుడిది.
6. ఈ పయ ప్రక్రియ అంతయు నాకు అర్ధం ఇయే భాషలోనూ వివరించబడినది.
సమ్మతి యొక్క పేరు మరియు సంతకం:
సంరక్షకుడు/ బంధువుల సంతకం:
దాత పేరు మరియు హోదా:
సమ్మతించు వాడి పేరు మరియు హోదా:
సమ్మతి ఐడి:
అడ్రెస్ :
సెల్ నంబర్ :
*রোগীর সম্মতি পত্র*
আমি সম্পূর্ণ খোলা মনে এই মর্মে সম্মতি জ্ঞাপন করছি যে আমি নিজে/আমার পরিচিত/আমার আত্মীয় (সঠিক যায়গায় টিক চিহ্ন দিন) রোগ সংক্রান্ত তথ্য একটি অনলাইন ই-লগ কেস রেকর্ডে (কেস রিপোর্ট) প্রদর্শিত হবে যেটা হোয়াটসঅ্যাপ (whatsapp) এবং ফেইসবুক (facebook)- এই ধরনের সোশ্যাল মিডিয়াতেও অবস্থিত থাকতে পারে এবং এতে আমার কোন আপত্তি নেই। আমি নিম্নবর্ণিত তথ্যগুলি বুঝেছি যেগুলি হলঃ
১) আমার স্বাস্থ্য সমস্যা সম্পর্কিত রোগের ইতিহাস, আমার শরীরের ক্লিনিক্যাল ও রেডিওলজিক্যাল ছবি (যেমন- এক্সরে, সিটি স্ক্যান, এম আর আই) সহ অন্যান্য পরীক্ষার রিপোর্টগুলো স্বাস্থ্যসেবা প্রদানকারীগন নিজেদের মাঝে শেয়ার করতে পারেন। পূর্বে এটি নিয়মিতভাবে কাগজে-কলমে করা হতো এবং এটি ছাড়াও, প্রযুক্তির উৎকর্ষ সাধনের সাথে সাথে, এই যোগাযোগ কে আরও দ্রুত করতে বিভিন্ন ইলেকট্রনিক ডিভাইস বা প্ল্যাটফর্ম ব্যবহার করে রোগের তথ্য শেয়ার করা হবে, যেমনঃ অনলাইন ই-লগ কেস রেকর্ডের মাধ্যমে।
২) আমার স্বাস্থ্যসেবা প্রদানকারিগন আমার রোগের তথ্য কোন রকম ব্যাক্তিগত তথ্য (যেমনঃ নাম, নম্বর, ফোন নম্বর, প্যান নম্বর, UID নম্বর, ইমেইল এড্রেস, বাড়ির ঠিকানা ইত্যাদি) ছাড়াই অনলাইনে প্রকাশ করবেন।
৩) আমার ব্যাক্তিগত তথ্য কখনই অনলাইনে প্রকাশ করা হবে না কেবল আমার সাংকেতিক নামই সকলে জানবে আমার প্রতিটি পত্রের জন্য।
৪) আমাদের প্রাথমিক উদ্দেশ্য হল কোন ব্যাক্তির ব্যক্তিগত রোগ সম্পর্কে বিভিন্ন তথ্য, বিভিন্ন পারদর্শিগনের সঙ্গে মতবিনিময় করে এক তথ্য ভান্ডার তোলা যাতে সেই ব্যক্তি তার রোগ সম্পর্কে সঠিক ধারনা পায়।
৩) আমি বুঝি যে, সবসময় আমার এই শারীরিক গোপনীয়তা নিশ্চিত করা সম্পূর্নরুপে সম্ভব নয়, কারন উদাহরন স্বরূপ যিনি আমার দেখভাল করছেন বা আমার পরিচিতেরা আমাকে চিনে ফেলতে পারেন।
৫) আমার রোগের তথ্য কখনই বিকৃত করা হবে না, কিন্তু প্রয়োজনে তার বাক্যের গঠন, ব্যাকরণ ইত্যাদিতে প্রয়োজনীয় পরিবর্তন আনা হতে পারে।
৬) আমার রোগ সম্বন্ধীয় তথ্যগুলি সারা পৃথিবীব্যাপি একটি অনলাইন ই-লগ কেস রেকর্ডের মাধ্যমে প্রচার করে ছড়িয়ে দেয়া হবে এবং সেটি বিভিন্ন স্বাস্থ্য সংক্রান্ত পত্রিকাগুলিতে প্রকাশ হতে পারে।
৭) এই অনলাইন ই-লগ কেস রেকর্ডে প্রদর্শিত চিকিৎসা সংক্রান্ত তথ্যগুলি কখনই আমার প্রাথমিক চিকিৎসকের উপদেশের বিকল্প হতে পারে না এবং আমার প্রাথমিক চিকিৎসকই আমার চিকিৎসার জন্য চূড়ান্ত সিদ্ধান্ত নিবেন।
8) উপরে উল্লিখিত তথ্য আমাকে আমার ভাষাতে পরিষ্কার করে বুঝানো হয়েছে। এতে আমার সম্মতি আছে।
সম্মতি প্রদানকারীর নাম ও সাক্ষর
সাক্ষ্যপ্রদানকারীর (অভিভাবক/আত্মীয়) সাক্ষর
সম্মতি/সাক্ষ্য প্রদানকারীর ঠিকানা ও মোবাইল নং
সম্মতি গ্রহণকারীর নাম ও সাক্ষর
Previous version of the forms including Hindi and Bengali
Hindi
http://bmjcaselogvivek.blogspot.com/2017/09/consent-forms.html?m=1
Bengali
https://drive.google.com/file/d/0B9Hr8RrSXSgYbHUtRW14NzZsRDg/Vite
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